Emergency Room Physicians

Though the vast majority of patients generally do well after surgery, some will present with serious medical or surgical problems, and even problems functional in origin may ultimately have grave consequences. Abdominal pain, nausea, vomiting, and dehydration occur with a certain frequency following Bariatric Surgery, most often in the first month or two after surgery. Specific approaches to these and other problems will be listed below.

After reviewing our section on General Principles, which should be taken into consideration first with any Bariatric Patient, please feel free to skim down to the following sections as they apply to your patient.

• Vomiting Reflux

• Dehydration

• Food Impaction-

• Stenosis

• Abdominal Pain

• Ulcers/NSAID Use

• Costochondritis

• Adjustable Gastric Band related problems of the Band Too Tight, Slip, Port Infection, Band Erosion

• Surgical Issues

General Principles

Please address these issues first:

2 or More Liters of IV Fluids – If IV hydration is required, please give at least 2 liters, usually of LR. This will meet immediate needs, and usually will leave a reserve to sustain the patient while they resume oral hydration at home.

Laboaratories –  CBC and CMP will usually cover most issues involved with weight loss surgery.  Consider an amylase and lipase when evaluating patients with severe abdominal pain.

Imaging  Studies – An abdominal/pelvic CT will usually the best study to help sort out Bariatric postoperative issues, such as leak, perforation, abscess, obstruction, or stones. Plain films are usually of limited value and are hard to interpret.  Upper GI can help with perforation or leak issues, or obstruction, but does not yield information on the status of the bypassed stomach and small bowel, and can leave contrast that confounds later studies such as CT.  Abdominal Ultrasound is helpful for gallstone patients, but this diagnosis can usually be made with a CT, which also helpful to evaluate other disease entities.

Vitamin Assessment/Cocktail – Vitamin depletion easily occurs in Bariatric patients for a variety of reasons, from noncompliance to lack of formulation efficacy, and may be difficult to ascertain clinically.  Please assess whether the patient has been keeping up with their vitamin and mineral supplements.  Unless you can be convinced that they are doing so on a regular basis, and their ER complaints are mild and they do not require an IV, please request the following laboratory assays: B12, B1, Vit D, Folate, and PTH, and then administer 1 amp MVI, 100 mg Thiamine, 2 mg Folate IV, and give 1000 mcg B12 IM.

Hypokalemia – Bariatric patients often develop an inexplicable hypokalemia in the first several months after surgery, and for longer periods in some patients. Treat with IV and oral supplementation as needed in the ER. Outpatients are usually well treated with 10 meq KCL capsules, # 100, 1 bid for repletion, and 1 qd for maintenance. The capsules can also be opened and the granules sprinkled on food.

Ask About NSAID Use –  Ask patients if they are taking NSAID’s.  Patients taking NSAID’s other than Tylenol may present with dramatic abdominal pain nonsurgical abdominal pain that is well treated with a proton pump inhibitors and Carafate.  Paitents taking large amounts of Tylenol of course can have abnormal liver function tests.

Notify the Bariatric Surgeon/Call for Consultation –  The task of first care physicians evaluating our Bariatric patients in the ER or urgent care setting in large part involves distinguishing serious issues from the otherwise simple but symptomatic. Our Bariatric Center staff can often help streamline an otherwise confusing and lengthy visit. Please call us at (907) 929-4263 about any of our patients seen in an emergency room or urgent care, please send us copies of your notes, and please refer our patients back to us for further care.  Please also feel free to call us for advice on Bariatric patients who similarly present, but have had their surgery elsewhere.  

Postoperative Problems

Vomiting Reflex – A frequent problem that troubles almost all of our patients sometime after surgery. Patients vomit after eating something that didn’t agree with them, after eating too much, or after eating too quickly. Once they start vomiting they may have difficulty stopping. Patients with Vomiting Reflex can present with sharp, aching epigastric pain, dehydration, and near emotional collapse. These symptoms may last hours to days, and is aggravated by attempts at taking anything by mouth, especially solid foods. Emesis usually consists of whatever has been ingested, or oral secretions which can have a whitish & foamy character.

Treatment includes reassurance, judicious anti-emetics (Phenergan 25 mg po or pr q4-6h, Zofran orally disintegrating tabs 4mg sl q 6h), and gentle attempts at po, starting with small quantities of simple comfort foods that the individual patient tolerates best, such as water, sugar free popcicles, tea, broth, and crackers. Patients may have to stay on this “Beginning” diet for several days, and should continue it for a day after symptoms resolve. Patients referred to the ER for IV hydration are best treated with at least 2 liters of fluid, vitamin assessment and cocktail, and Phenergan IV or IM. Encourage patients to try to control these episodes on their own by understanding that they do occur from time to time and are usually self limited, and by otherwise avoiding irritating foods or eating behaviors, and by learning to switch to the “Beginning” diet at the first signs of trouble.

Dehydration – Dehydration is a common problem in Bariatric patients, especially in the first month following surgery. It may occur without vomiting in patients having difficulty with the dietary and emotional changes following the surgery. Encouraging them to resume po is sufficient treatment in many patients, including having drink a bottle of water in the exam room while visiting with sympathetic staff. Patients may require IV hydration, best done with at least 2 liters of IV fluid, vitamin assessment and cocktail, and CBC and metabolic panels drawn to rule out electrolyte disturbances and as part of the general assessment.

Food Impaction -This actually occurs much less frequently that expected.  Patients present with emesis, pain, and with relatively sudden inability to keep anything down. Patients should be asked if they have tried to take meats or other solid foods in the first days or weeks after surgery, when they should be on only liquids or pureed, but food impaction can occur at any time after surgery. Emesis may be persistent and dark colored, stained by the impacted material. Initial evaluation includes UGI, which will reveal a complete obstruction at the gastrojejunostomy. Treatment includes referral for endoscopic disimpaction versus a trial of Adolph’s or other meat tenderizer, one tbsp. in a glass of water. Judgement is necessary in this regard as there is concern for tenderizer induced esophageal injury.

Stenosis – In our experience anastomotic stenosis usually occurs at least 3 weeks postoperatively. Stenosis usually presents with a progression of symptoms, beginning with several days of difficulty with solids, followed by difficulty with pureed foods, then inability to take liquids. It may be confirmed with UGI, with subsequent EGD whenever adequate stomal patency is not well documented, but some strictures are incomplete and not clearly documented with UGI contrast material, yet tight enough to be symptomatic with solids or thick liquids. Treatment involves dilatation up to 1.2 cm, followed by Carafate and a proton pump inhibitor, with a repeat dilatation one week later to insure good patency.

Abdominal Pain – Abdominal pain occurs frequently in bariatric patients, though it decreases in frequency after the first year. It may occur not only in the epigastrium or upper quadrants, but also in the lower quadrants, and suprapubic area, which is somewhat difficult to understand in patients who have undergone an upper abdominal procedure. Abdominal pain may be associated with emesis, though not usually with fevers. It may be of relatively sudden onset, and quite severe. We have seen relatively few obstructions or abscesses as confirmed causes of our patients presenting with abdominal pain, and when these have occurred they were for the most part otherwise readily apparent. Postulated etiologies for idiopathic episodes of abdominal pain include atony of the bypassed stomach, spasm of the Roux limb, traction of the tube gastrostomy site against the abdominal wall, and renal stones. The latter may be a frequent cause of lower abdominal or flank type pain. Two frequently presenting known causes, Ulcers/NSAID Use, and Costochondritis, are discussed in following sections. Abdominal pain has also been a chief complaint of patients presenting in emotional collapse after trying to deal with the many changes required after Bariatric Surgery. This is usually elucidated by a thorough and prolonged visit and a judicious work-up, and is well treated with much reassurance that the patient is actually on tract (is not having an unexpected amount of difficulty with the postoperative recovery and adaptation to the postoperative lifestyle), and with a subsequent support group meeting. Patients presenting with significant abdominal pain should be evaluated as indicated with CBC, CMP, amylase, lipase.  Abdominal/Pelvic CT with oral and IV contrast seems to be the best imaging study, and will render information regarding leaks, abscess formation, distention of the bypassed stomach and/or biliary limb, obstruction, or kidney stone (see emergency section). In the majority of cases no cause will be determined for the pain, and it will not recur, though it may have initially been quite severe and have prompted a 24 hour admission for observation and pain relief. Judicious narcotics and anti-emetics usually are very helpful while waiting for the pain to resolve. Patients presenting with a deep aching LUQ abdominal pain may have atony of the bypassed stomach, and a few have responded remarkably well to Reglan.

Ulcers/NSAID Use – Abdominal pain in our patients may be related to inflammation of the upper GI tract from the use of proscribed NSAID’s.  A patient may have arthritis that continues to trouble them postoperatively, despite impressive weight loss. Such patients may then resort to Ibuprofen in any of its many forms, or other NSAID’s, even though these are known to frequently cause GI upset.

With or without NSAID use patients may develop ulceration and inflammation of the esophagus, of the gastric pouch, or of the anastomosis between the pouch and Roux limb (gastrojejunostomy). The pain is typically epigastric, radiates to the back and sides, and is deep, sharp, and burning. Initial work-up may include an UGI, though the best study will be EGD. Current treatment includes cessation of all NSAID’s, other than Tylenol, AcipHex, 20 mg bid or Nexium 40 mg bid, # 60, and Carafate, 2 – 8 0z bottles, 1 gram (10cc) 1 hour before meals and qHS, with a referral to gastroenterology for EGD.

Costochondritis – Patients frequently present with complaint of epigastric pain that on examination is actually just off to either side (usually the left), and is exactly reproducible by firm palpation of the rib margin. This almost always resolves with a 1 or 2 injections (staged weeks apart) of 1cc Celestone and 2cc 0.5% Marcaine.

Wound Infection/Fluid collections – (also discussed in Surgical Problems)-  Wound infections and fluid collections may be somewhat difficult to determine in patients with generous subcutaneous tissues, whose wounds will not close rapidly after they are opened for a negative diagnostic exploration. Purulent discharge is of course clear evidence. Patients complaining of the “feeling of something in their wound” should be evaluated with ultrasound. Be sure to ask the Radiologist if there is a subcutaneous collection of fluid seen on the “negative” CT done for abdominal pain. Treatment of course is incision and drainage and antibiotics, though the entire wound may not have to be opened to drain a hematoma or seroma, infected or not.

Adjustable Gastric Band Too Tight – Patients with adjustable gastric bands may have them adjusted too tightly. This may either be accidental, or intentional as part of a somewhat zealous but misguided effort for additional weight loss.   Patients will say that they had fluid added to their band either days or even months before, and have been unable to take solids or even liquids other than water.  They will also presents with significant reflux, at times even involving night time aspiration, dysphagia. Evaluation involves an UGI to assess for complete obstruction, placement of the band, and esophageal dilatation. Patients presenting with dehydration should be assessed with laboratory studies and considered for IV hydration. Treatment involves taking fluid out of the band.  This can be done with a noncoring port access needle in consultation with a weight loss surgeon, and may best be done under fluoroscopy.  The simplest approach may be to hydrate the patient, and then to refer them to the weight loss surgeon or experienced radiologist the next day.

Adjustable Gastric Band Slip – Adjustable gastric bands are intended to be precisely located just below the GE junction, with just a bit of gastric tissue located above it.  Three should not be a sizeable pouch, above it, usually meaning less than the size of a vertebral body as seen on UGI, and the pouch should not flop over the band on either side.  If the pouch is larger than expected, or flops over the band, the patient, until stated otherwise, has a presumed slip.

Slips usually present with a certain degree of obstruction, from difficulty taking solids to complete obstruction with intractable nausea and vomiting and abdominal pain.  If minimally to moderately symptomatic, they can be hydrated and referred to a Bariatric surgeon for timely followup.  Slips involving severe abdominal pain and elevated WBC may be complicated by gastric ischemia, and require urgent referral and evaluation for urgent/emergent band removal.

Adjustable Gastric Band Port Infection – Band ports may become infected.  Such infections are typical, with redness, swelling, and tenderness in the area of the port, and an elevated WBC.  Aspiration from the area around the port may yield pus, and CT may show inflammation around the catheter tract.

Treatment can be initiated with IV and oral antibiotics, and usually patients can be referred for outpatient followup with a Bariatric surgeon.

Adjustable Gastric Band Erosion – Infrequently, gastric bands can erode into the stomach.  Erosions do not usually present with catastrophic spillage of gastric contents, as the band is usually well encapsulated.  Rather, the patient presents with days to weeks if epigastric and left upper quadrant pain, an elevated WBC, and at times local signs suggesting a port infection.  Imaging studies are usually not diagnostic, but EGD will show the band having eroded into the stomach.

Stable patients may be referred for outpatient followup.  Compromised or septic patients should be considered for immediate ex plantation, with immediate consultation with an available weight loss surgeon.

Surgical Problems

The following information is presented to help surgeons preparing to operate, either emergently or electively, on patients who have undergone Roux-en-Y Gastric Bypass (RNY GBP) at our Center. References will be made to our experiences operating on patients who received Bariatric surgery elsewhere and who have returned toAlaska. Other than abdominal wall hernias, our patients have only infrequently required re-exploration for problems specifically related to the index RNY GBP, with the perhaps 2 to 4 (of our almost 2000 patients as of 2011) presenting annually with perforated anastomotic ulcers, and perhaps 1 to 2 presenting every year with Peterson defect related internal hernias, with almost none of these occurring in patients done after we began to tightly close this defect in 2006.

Operative Anatomy –  Patients who received surgery at our Center between September of 2000 and June of 2002 generally underwent a 7 cm vertical pouch, retrocolic/retrogastric, RNY gastric bypass with Roux and Bypassed limbs of approximately 100 cm each, and with concurrent cholecystectomy/ intra operative cholangiogram, wedge liver biopsy, and tube gastrostomy.